Prescription of therapeutic exercise in migraine, an evidence-based clinical practice guideline
The Journal of Headache and Pain volume 24, Article number: 68 (2023)
The main objective of this clinical practice guideline is to provide a series of recommendations for healthcare and exercise professionals, such as neurologists, physical therapists, and exercise physiologists, regarding exercise prescription for patients with migraine.
This guideline was developed following the methodology and procedures recommended in the Appraisal of Guidelines for Research and Evaluation (AGREE). The quality of evidence and strength of recommendations were evaluated with the Scottish Intercollegiate Guidelines Network (SIGN). A systematic literature review was performed and an established appraisal process was employed to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology).
The evaluation of the current evidence, the elaboration of the grades of recommendation, and their validation show a B grade of recommendation for aerobic exercise, moderate-continuous aerobic exercise, yoga, and exercise and lifestyle recommendations for the improvement of symptoms, disability, and quality of life in patients with migraine. Relaxation techniques, high-intensity interval training, low-intensity continuous aerobic exercise, exercise and relaxation techniques, Tai Chi, and resistance exercise obtained a C grade of recommendation for the improvement of migraine symptoms and disability.
Migraine is the second leading cause of disability in the world after low back pain . It is a neurological condition with a global prevalence of 14.4%, with the peak prevalence and years of life lived with disability occurring between ages 35 and 39 years . The impact generated on the patient’s various social and family dimensions induces a decline in quality of life and a high economic cost due to work absenteeism, a decrease in work efficiency, and increased healthcare costs [1, 3, 4].
Pharmacological interventions are the most common approaches, typically consisting of the use of non-steroidal anti-inflammatory drugs and triptans for acute management [5, 6]. Prophylactic drugs, such as topiramate or valproic acid, are recommended for chronic migraine [5, 6]. Other pharmacological approaches have been developed in recent years, including the human monoclonal antibody erenumab, botulinum toxin, ditans, and gepants, with good results in the reduction of the frequency of migraine and evolution of migraine attacks [7,8,9]. However, the main problem with these interventions is their concomitant adverse effects, such as the increase in blood pressure with triptans use, the risk of allergic reaction with monoclonal antibodies, the transient development of blepharoptosis and muscle weakness produced by the injection of botulinum toxin, and interaction with other drugs [6,7,8,9,10].
In addition to pharmacological treatment, behavioral change interventions are fundamental in the clinical management of migraine. These treatments include management of stress, sleep, diet, and exercise [11, 12], of which aerobic exercise and yoga modalities are proposed as preventive alternatives for migraine . Exercise prescription for migraine improvement appears to be a safe and effective intervention that could decrease migraine symptoms and disability and increase quality of life. Aerobic exercise has been the most studied modality [13, 14].
Migraine and exercise information disseminated on social networks has increased exponentially in recent years; however, the quality of that information is questionable . Several international scientific societies recommend the practice of exercise as part of the therapeutic approach to migraine. The French Headache Society includes physical exercise as part of the non-pharmacological treatment of migraine headaches ; the Danish Headache Society agrees with a similar recommendation and also includes relaxation and postural exercises ; and the American Headache Society recommends regular exercise as part of the biobehavioral treatment of migraine management and prevention .
The recommendations of the various headache societies for treatments involving exercise for migraine have one characteristic in common: exercise is mentioned in a very general way, and the various exercise modalities that can be used for migraine treatment are not mentioned in depth. Current scientific evidence has not yet determined the adequate exercise prescription parameters for patients with migraine. Also, there are still no clinical practice guidelines on exercise prescription for migraine. Therefore, we consider it necessary to develop a guide to help clinicians who treat headaches so they can make better recommendations or provide a more specific exercise prescription.
The main objective of this clinical practice guideline is to provide a series of recommendations regarding different exercise modalities that could be effective in the treatment of migraine, and other lifestyle recommendations that could increase the efficacy of exercise interventions, for healthcare and exercise professionals, such as neurologists, physical therapists, and exercise physiologists, so as to better treat patients with migraine. For this proposal, we reviewed the current evidence that shows which exercise interventions improve migraine symptoms (intensity, frequency, and duration), disability, and quality of life. Moreover, the intention of this guideline is to provide parameters of exercise prescription for each exercise modality that could be adapted depending on the patient’s characteristics (e.g. migraine frequency, physical condition, and patient’s preferences). It is not a standard of medical care that determines the exercise intervention approach for migraine treatment. Patients’ clinical presentation, experiences, and expectations, as well as clinicians’ experiences and expertise should guide the exercise prescription based on the best recommendations of the current evidence.
Overall design and organization
Content experts were appointed by the Institute of Neuroscience and Sciences of Movement (INCIMOV) from the La Salle University Center for Advanced Studies (CSEULS) to conduct a systematic review for the development of clinical practice guidelines regarding exercise prescription for patients with migraine. The guideline was reported in accordance with the Reporting Items for Practice Guidelines in Healthcare (RIGHT) statement , and the Appraisal of Guidelines, Research and Evaluation (AGREE) checklist  was consulted to ensure the quality of the guideline.
Funding and support
The Professional College of Physiotherapists of the Community of Madrid provided funding and support for this clinical practice guideline. This institution did not take part in the development of the recommendations.
Guideline working group
The task force for the Evidence-Based Practice Guidelines for Exercise Prescription in Migraine Patients consisted of 3 groups: an advisory committee and panel, an expert consensus group, and a scientific evidence evaluation group. Task force members came from a wide range of disciplines, including medicine, physiotherapy, physical activity and sport sciences, and psychology. The scientific-technical knowledge and skills of the task force were related to exercise prescription, migraine diagnosis and treatment, evidence-based medicine, and research methodology.
Registration and protocol
The present clinical practice guideline was registered in the Practice guideline REgistration for transPAREncy (PREPARE) with the registration number PREPARE-2023CN046.
A systematic review of the evidence regarding exercise efficacy for improving the symptoms, disability, and quality of life in patients with migraine was performed. This review was elaborated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist . Moreover, this study was previously registered in PROSPERO, an international register for systematic reviews (CRD42022316319).
The search strategy combined medical subject headings (MeSH) and non-MeSH terms and was applied to the following databases without language or time restrictions: MEDLINE (PubMed), Cochrane, EBSCO, Web of Science, and Google Scholar. The most important terms were “Migraine” and “Exercise,” and the last search was conducted in December 2022. Various sub-searches were developed due to the variety of exercise modalities available for the treatment of migraine. The search strategy information is available in the Supporting Information Appendix S1.
Two independent reviewers conducted the search using the same methodology. If any difference emerged during this phase, it was resolved by consensus. Moreover, original articles were manually screened, and the authors were contacted for further information if necessary.
Selection criteria and data extraction
Systematic reviews, randomized controlled trials, quasi-experimental trials, cohort and case–control designs, case series, case reports, and narrative reviews were screened and included in this review. Any form of study that evaluated the effects of exercise on the symptoms, disability, and quality of life of patients with migraine was of relevance for the development of the present clinical practice guidelines.
A specified list of inclusion and exclusion criteria was elaborated for the screening of articles based on the Population, Intervention, Comparator and Outcome (PICO) measure model . The inclusion criteria for the participants in the articles included were patients with episodic or chronic migraine, diagnosed by a physician based on any of the International Classification of Headache Disorders (ICHD) editions , and age 18 years or older. The intervention must be or include exercise in any modality (e.g., aerobic, yoga, resistance training), and the comparator could be any other form of evidence-based exercise intervention that has been shown to be effective for migraine, placebo, or waiting list. Finally, the outcome measures included were pain intensity; migraine attack frequency, defined mainly as days with migraine per month; and duration of migraine attacks, evaluated primarily as the number of hours per migraine attack. Disability and quality of life measures were also analyzed.
For the selection criteria and data extraction, 2 independent reviewers examined the title, abstract, and keywords of each article using the inclusion and exclusion criteria. A full-text article review was similarly conducted for the final elaboration of the set of articles included for the clinical practice guideline recommendations. If any difference emerged during this phase, it was resolved by discussion, mediated by a third reviewer .
Methodological quality and risk of bias assessment
Two independent reviewers assessed the methodological quality of the studies included in the review. Systematic reviews were evaluated with the Modified Quality Assessment Scales for Systematic Reviews (AMSTAR), developed by Barton et al. . The Physiotherapy Evidence Database (PEDro) scale was used for the assessment of the randomized controlled trials and the quasi-experimental trials . Cohort studies were evaluated with the Newcastle–Ottawa Quality Assessment Scale (NOS) . For the evaluation of the case series studies, we employed the National Institutes of Health (NIH) Study Quality Assessment Tool for Case Series Studies . Finally, we assessed the methodological quality of the narrative reviews with the Scale for the Assessment of Narrative Review Articles (SANRA) . We also assessed the risk of bias in the systematic reviews and randomized controlled trials. The Risk of Bias in Systematic Reviews (ROBIS) tool was used for the evaluation of the systematic reviews, and the Cochrane revised Risk of Bias 2.0 scale (RoB 2.0) was used for the evaluation of the randomized controlled trials and the quasi-experimental studies [30, 31].
The inter-rater reliability between the 2 reviewers was evaluated with κ. This statistic shows a low level of agreement if κ < 0.5; κ of 0.5–0.7 shows a moderate level of agreement; and κ > 0.7 shows a high level of agreement . If any disagreement appeared in the quality assessment score, it was resolved by consensus, mediated by a third independent reviewer.
Level of evidence and grades of recommendation
Once the methodological quality and risk of bias assessments were performed, the Scottish Intercollegiate Guidelines Network (SIGN) was used to evaluate each study’s level of evidence and to determine the recommendation grade for each exercise intervention. This tool was designed for the development of evidence-based clinical guidelines, and it has a series of advantages: the methodological quality of each study determines the level of evidence; guideline developers must consider the generalizability, applicability, and consistency of each intervention; the clinical impact of the evidence creates a clear link between the evidence and the recommendation; and grades of recommendation are based on the strength of the supporting evidence, taking into account its overall level and the considered judgment of the guideline developers . Table 1 shows the criteria for the levels of evidence and grades of recommendation.
For the development of each intervention summary, we introduced “improve” or “decrease” (grade A), “likely to” (grade B), “might” (grade C), or “remotely” (grade D) depending on the grade of recommendation and the sum of studies that support or negate each intervention efficacy based on the various migraine variables (symptoms, disability, and quality of life). For example, if an intervention achieved a B grade of recommendation and 3 or more studies found a positive effect on pain intensity, it “is likely to decrease pain intensity”. However, if this same intervention had only 1 study that found a positive effect on quality of life, it “remotely improve quality of life”.
Subgroups of patients with migraine were established in the present clinical practice guideline to distinguish between episodic and chronic migraine. The ICHD defines chronic migraine as a headache occurring on 15 or more days per month for more than 3 months, which, on at least 8 days per month, has the features of migraine headache . If the headache and migraine features are of lower frequency, it is considered an episodic migraine. This distinction is important, given that studies regarding exercise interventions on patients with migraine could include one or both diagnostics and influence the results obtained.
We provided operational definitions for the various exercise modalities and multimodal interventions of this clinical practice guideline. These operational definitions summarize the main characteristics of the various interventions.
For the general exercise recommendations, we focused on the data from the systematic reviews published, and for the specific exercise modalities recommendations we focused on the available RCTs.
Guideline review process and validation
For the evaluation and validation of the guidelines’ content, a panel of experts was organized. This panel, as mentioned in the guideline working group section, consisted of 8 physical therapists, 4 of whom were also physical activity and sports professionals, a physician, and a psychologist, all with extensive clinician and research experience in the treatment of patients with migraine and exercise prescription. Operational definitions of each intervention, methodological quality, risk of bias, level of evidence, recommendation grade, prescription parameters, and intervention summary were shown to the panel of experts in a presentation during a meeting in June 2022. The experts had to validate these various intervention categories. For this validation process, the experts used a 5-point Likert scale: (1) strongly disagree, (2) somewhat disagree, (3) neither agree nor disagree, (4) somewhat agreement, (5) strongly agree. Moreover, they could add any correction or suggestion to the various categories. After some rounds of deliberation, the experts reached a consensus and determined the validity of each modality and category.
The procedure for updating the clinical practice guidelines will be structured according to the Checklist for the Reporting of Updated Guidelines  and by analyzing the amount and relevance of emerging evidence for exercise prescription in patients with migraine.
A total of 60 studies were included in the clinical practice guidelines. Our article search strategy and selection process are shown in the flow diagram (Fig. 1). The included studies were 1 umbrella review and meta-meta-analysis , 6 systematic reviews and meta-analyses [13, 36,37,38,39,40], 29 randomized controlled trials [41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69], 4 cohorts [70,71,72,73], 1 case series , and 19 narrative reviews [75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93]. The methodological quality and risk of bias assessment for each study are shown in Tables 2, 3, 4, 5, 6, and 7, and in Figs. 2, 3, and 4. The agreement between the evaluators in the quality assessment of the studies was high in the PEDro (κ = 0.857), RoB 2.0 (κ = 0.708), and NIH (κ = 1.000) scales, and moderate for the NOS (κ = 0.692) and SANRA scales (κ = 0.681).
A total of 2493 patients with migraine were included in the articles that compose this clinical practice guideline, 1692 in the intervention groups and 801 in the control group. From this total sample, 1699 patients presented an episodic migraine diagnosis in 28 studies [41,42,43,44,45, 47,48,49,50,51,52,53,54, 57,58,59, 61,62,63,64, 66,67,68,69,70,71, 73, 74], and 524 had a chronic migraine diagnosis in 6 studies [44, 55, 65, 70, 72, 73]. However, 270 individuals were included in studies that did not specify the number of episodic and chronic migraine diagnoses [46, 56, 60]. The mean age range of the patients included in the studies was 29 to 51 years, and the mean body mass index range was 22.04 to 35.8 kg/m2. Of the total sample, 2133 were women and 360 were men.
Migraine frequency was measured by attacks per month or days with migraine per month; pain intensity was evaluated with the Visual Analog Scale (VAS), the Numeric Pain Rating Scale (NPRS), the Numeric Rating Scale (NRS), or other ordinal scales (e.g., 0 = no pain; 1 = mild; 2 = moderate; 3 = severe). Pain duration was registered as average minutes per attack, the average duration of headaches in hours, hours per day, hours per month, duration of headache episodes in days or days with a migraine episode. Disability was evaluated with the Migraine Disability Assessment questionnaire (MIDAS), the Headache Impact Test-6 (HIT-6), and the Headache Disability Index (HDI), and quality of life was measured with the Migraine Specific Quality of Life Questionnaire (MSQoL), the Migraine-Specific Quality of Life Questionnaire version 2.1 (MSQv 2.1), and the Quality of Life Profile for the Chronically Ill (PLC).
Evidence statements and recommendations
Grade B of recommendation
This modality contains general advice for aerobic exercise without a specific definition or accurate exercise prescription parameters.
It obtained a B grade of recommendation based on the results of 1 umbrella review with meta-meta-analysis , and 4 systematic reviews with meta-analysis [13, 36, 38, 40] (Table 8). Professionals should consider that prescription of aerobic exercise for patients with migraine is likely to decrease pain frequency, intensity, and duration, and to improve quality of life.
Moderate-intensity continuous aerobic exercise
This modality is defined as an exercise intervention that uses large muscle groups, with increased breathing and continuously maintaining a heart rate at an intensity from 12–16 on the Borg perceived exertion scale, a 64%-76% estimated maximum heart rate (HRmax), a 40%-59% heart rate reserve (HRR), or a 40%-59% oxygen uptake reserve (VO2R) .
It reached a B grade of recommendation based on the results of 6 randomized controlled trials [41, 49, 50, 62, 63, 67], 5 quasi-randomized controlled trials [47, 56, 61, 64, 66], and 1 cohort study  (Table 8). A total of 564 participants were included in these studies, of whom 436 were diagnosed with episodic migraine, 103 were not clearly differentiated between episodic or chronic migraine diagnoses, and 25 were healthy controls.
Professionals should consider that moderate-intensity continuous aerobic exercise, from an 8-week onward intervention applied 3 times per week, is likely to improve headache frequency, might improve pain intensity, and remotely improves attack duration, disability and quality of life in patients with episodic migraine (Table 9).
Yoga is defined as a mind–body intervention that includes 3 components: physical alignment poses (asanas), breathing techniques, and mindfulness exercises (meditations). Its intensity varies from light to vigorous and includes strength, balance, coordination, and flexibility components [96,97,98].
It obtained a B grade of recommendation based on the results of 2 systematic reviews with meta-analysis [37, 39], and 6 randomized controlled trials [45, 51, 52, 54, 58, 68] (Table 8). A total of 467 patients with episodic migraine were included in these studies.
Professionals should consider that yoga, including asanas, breathing and relaxation techniques, and meditation is likely to improve headache frequency and disability and remotely improves pain intensity and attack duration, from a 6-week onward intervention applied 3 times per week for episodic migraine (Table 9).
Exercise and lifestyle recommendations
This recommendation is defined as the conjunction of interventions directed to implement habits regarding physical activity, mealtimes, sleep, medication consumption and stress management. Some specific recommendations included here are focused to achieve regular exercise, regular sleep hours along the week, keeping consistent meal hours, adequate hydration, relaxation for stress management and avoiding excessive medication intake.
This modality achieved a B grade of recommendation based on the results of 2 randomized controlled trials [44, 55], and 3 cohorts [70, 72, 73] (Table 8). A total of 954 individuals participated in these studies, divided in 490 episodic and 464 chronic migraine patients.
Professionals should consider that exercise prescription and physical activity in conjunction with other lifestyle recommendations is likely to decrease pain frequency, might improve pain intensity and attack duration, and remotely decrease the disability of both episodic and chronic migraine patients after 6 weeks of intervention with 3–5 sessions per week. Moreover, it remotely improves the function and quality of life of patients with chronic migraine (Table 9).
Grade C of Recommendation
These are defined as techniques commonly employed for headache treatment that include progressive muscle relaxation to help patients identify and discriminate between tense and relaxed muscle groups, autogenic training or cued relaxation, visualization and guided imagery, diaphragmatic breathing, and mini-relaxation, which focuses on a limited number of muscles in the head, neck, and shoulders .
This modality reached a C grade of recommendation based on the results of 3 randomized controlled trials [59, 60, 67] (Table 8). A total of 311 individuals participated in these studies, of whom 126 had episodic migraine, 139 had no clear differential diagnosis between episodic or chronic migraine, and 46 were healthy controls.
Professionals should consider that relaxation techniques remotely improve headache frequency after at least 6 weeks, from 1 session per week to daily sessions, in patients with episodic migraine. It remotely improves pain intensity after 12 weeks of intervention with 3 sessions per week in patients with episodic migraine (Table 9).
High-intensity interval training
This modality is defined as exercise that involves alternating periods of high-intensity aerobic exercise at or below maximal oxygen uptake with light recovery exercise or no exercise between intervals .
Professionals should consider that high-intensity aerobic interval training might improve the frequency of pain and remotely improve the intensity of pain, attack duration, and disability after 8 weeks of intervention with 3 sessions per week in patients with episodic migraine (Table 9).
Low-intensity continuous aerobic exercise
The definition of this modality is any activity that uses large muscle groups, increases breathing and heart rate, and can be maintained continuously and rhythmically, using aerobic metabolism to extract energy, at an intensity from 8–11 on the Borg perceived exertion scale, 50%-63% HRmax, 20%-39% HRR, or 20%-39% VO2R .
This modality achieved a C grade of recommendation based on the results of 1 randomized controlled trial , and 1 quasi-randomized trial  (Table 8). A total of 40 episodic and 60 chronic migraine patients participated in these studies.
Professionals should consider that low-intensity aerobic exercise remotely improves headache frequency, pain intensity, and total duration per month of migraine after 6 weeks of intervention with 3 sessions per week in patients with episodic migraine (Table 9).
Exercise and relaxation techniques
This modality consists of the combination of exercise and relaxation techniques, previously defined.
This combination of techniques reached a C grade of recommendation based on the results of 2 randomized controlled trials [48, 58], and 1 quasi-randomized trial  (Table 8). A total of 119 patients with migraine were included in these studies, of whom 91 were patients with episodic migraine and 28 had no clear differential diagnosis between episodic or chronic migraine.
Professionals should consider that exercise and relaxation techniques might improve pain intensity and remotely improve the frequency and disability of episodic and chronic migraine patients after 6 weeks of intervention with at least 2 days per week of sessions (Table 9).
Neck strength exercise
This exercise modality consists of motor control and resistance exercise directed to the deep and superficial muscles of the neck and craniocervical regions with the aim of gaining strength.
This modality achieved a C grade of recommendation against this intervention based on the results of 1 randomized controlled trial  (Table 8). This study included a total of 42 patients with episodic migraine.
Professionals should consider that neck resistance exercise might not improve migraine frequency, pain intensity, or disability of patients with episodic migraine after 8 weeks of intervention with at least 1 supervised session per week and daily home exercises performed twice a day (Table 9).
Tai Chi is considered a balance training program that contains slow movements that stress postural control, can be performed in groups and requires the person to move body parts gently and slowly while breathing deeply .
This modality obtained a C grade of recommendation based on the results of 1 randomized controlled trial , and 1 narrative review  (Table 8). The randomized controlled trial included a total of 73 patients with episodic migraine.
Professionals should consider that Tai Chi remotely improves migraine frequency in episodic migraine patients after 12 weeks of intervention with 5 sessions per week. It might not improve pain intensity or attack duration (Table 9).
Resistance exercise is defined as an exercise modality that provokes an improvement in functional performance by increasing muscular strength, power, speed, hypertrophy, local muscular resistance, motor performance, balance, and coordination .
Professionals should consider that resistance exercise remotely improves pain frequency and intensity and disability of patients with episodic migraine after 8 weeks of intervention with at least 3 sessions per week (Table 9).
Grade D of recommendation
Qi-Gong is a series of exercises that incorporates elements of slow, gentle movement, and awareness and regulation of breathing, as well as the intentional direction of thoughts, attention, imagery, and sensation .
Professionals should consider that Qi-Gong remotely improves pain frequency and disability of patients with episodic migraine after 3 months of intervention with daily sessions. It might not improve the pain intensity of patients with episodic migraine (Table 9).
Prescription exercise parameters
The prescription parameters used in each study are included in Table 10. The summary of the prescription parameters recommended for prescribing each exercise modality in patients with migraine is shown in Table 11.
Limitations and future directions
The purpose of this clinical practice guideline is to describe in depth the scientific evidence on exercise prescription for patients with migraine in order to facilitate decision making by physical therapists and other health and exercise professionals. Analysis of the information incorporated herein shows that in the last decade there has been an increase in the number of studies on the effectiveness of exercise in patients with migraine. Most of the research we included presented positive effects; however, there are several limitations in these studies that should be considered when interpreting the results and considering the future direction of studies in this area.
One of the most important limitations of the analyzed and included evidence is related to the comparisons used in the studies: the control groups employed a wide variety of interventions, including waiting lists, placebo, and pharmacological treatments. This limitation is fundamentally derived from ethical requirements, given that pharmacotherapy is established as the first line of treatment, and this situation substantially complicates determining the real magnitude of the effect of the various exercise modalities on migraine.
In relation to the above, it should also be considered that it is not possible to establish a real placebo comparison for treatments in which behavior modification is promoted, as in the case of exercise.
Another limitation is that most of the studies based on exercise and migraine evaluated immediate response, in short and intermediate terms, and only a few studies measured long-term effects. We believe that it is necessary to design studies that assess long-term effects to identify whether the effect is dependent on the duration of the exercise intervention or whether the effect is maintained for a long time after the intervention. At least a one year follow up would be recommended . It would also be necessary to perform analyses that identify the level of adherence to the interventions related to exercise.
When using exercise with migraine patients the question arises as to whether it is appropriate to exercise with very intense pain. There is no evidence about the effects of the exercise while the patient is under severe pain, however we consider we must be cautious when prescribing exercise. If the patient has very intense pain, very frequently and/or the exercise is a clear trigger factor, the most appropriate recommendation would be to prescribe a gradual and individualized exposure to exercise.
There remain some unknowns about the effect of exercise on the patient with migraine that need to be addressed in future research. Studies do not currently compare which exercise modality is most effective in reducing the frequency, duration, and intensity of migraine pain, and it would be interesting to identify whether integrating various exercise modalities (e.g., aerobic exercise and strength training) is more effective than using each modality individually.
The evidence currently available does not clarify whether the improvement of physical variables through exercise has an impact on the frequency, duration, and intensity of migraine. It would be necessary to perform studies that introduce as covariates the level of physical activity, strength, or the improvement of range of motion or cardiovascular capacity and determine whether these variables are associated with the improvement of clinical variables.
Finally, we consider it opportune that subsequent studies take into account the psychological status of the patients to better select the most appropriate exercise modality, due to the growing number of studies that point out the impact that kinesiophobia has on patients with migraine [94, 104, 105]. Considering this factor, prescribing an exercise modality, such as gradual exposure to exercise, may be the most appropriate selection for this patient profile.
This clinical practice guideline has followed a rigorous process of quality assessment of the scientific evidence related to the effectiveness of exercise on migraine. Our analysis indicates that aerobic exercise, moderate intensity aerobic exercise, yoga, and lifestyle recommendations that include exercise present a grade B of recommendation for reducing the frequency, duration, and intensity of pain and improving the quality of life in patients with migraine.
The exercise modalities that are effective and have a grade C of recommendation are relaxation techniques, interval training at high intensity, continuous low-intensity aerobic exercise, Tai Chi, and resistance training (strength training). Finally, grade D of recommendation was given to Qi-Gong.
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We would like to thank the collaboration of the Professional College of Physiotherapists of Community of Madrid for granting the funding for this project.
The Professional College of Physiotherapists of the Community of Madrid provided funding and support for this clinical practice guideline. This institution did not take part in the development of the recommendations.
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La Touche, R., Fierro-Marrero, J., Sánchez-Ruíz, I. et al. Prescription of therapeutic exercise in migraine, an evidence-based clinical practice guideline. J Headache Pain 24, 68 (2023). https://doi.org/10.1186/s10194-023-01571-8